Demographic profile of Member States
The countries belonging to the WHO South-East Asia Region are Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. The Region in general has a high population density, and displays great inequities and diversities across and within countries in terms of socioeconomic indicators, ethnicity, religion, gender, geography, and quality of health care (Table A9.1). In designing appropriate strategies for cervical cancer control, it is crucial to recognize these inequities since they have an impact on access to essential health services, quality of care received and health outcomes.
Table A9.1. Socio-demographic profiles of Member States of the South-East Asia Region
Country
Bangladesh 156 595 103.2 30.5 1 049.5 750 55.1 (2011) 71
Bhutan 754 115.8 34.8 15.3 2 560 45 (2005) 69
Indonesia 249 866 101.3 49.9 126.4 3 563 92 (2011) 73
Maldives 345 101.7 40.0 1 092.9 6 244 98 (2005) 78
Myanmar 53 259 94.3 31.4 76.8 90 (2011) 68
Nepal 27 797 95.2 16.8 182.4 699 47 (2011) 69
Sri Lanka 21 273 96.4 18.3 316.4 2 922 90 (2010) 78
Thailand 67 011 96.2 44.1 129.4 5 480 92 (2005) 79
Timor-Leste 1 133 103.3 29.5 72.6 1 179 53 (2010) 68
GDP – gross domestic product
Estimation of the expected number of target beneficiaries is one of the key requirements for planning a health programme. In any country, approximately one fourth of the total female population belong to the 30 to 49 years age group – the commonly recommended target age for cervical cancer screening. The number of girls estimated to be in each single age cohort from 9 to 13 years in the South-East Asia Region for 2013 is given in Table A9.2. The approximate number of girls requiring HPV vaccination each year can be calculated from the table.
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Table A9.2. Estimated number of girls in different single age cohorts in Member States of the South-East Asia Region, 201313
Country Estimated female population (in thousands) in single age cohorts (9–13 years)
9 years 10 years 11 years 12 years 13 years
Bangladesh 1 529 1 549 1 558 1 559 1 556
Bhutan 7 7 7 7 7
Democratic People’s Republic
of Korea 174 178 181 186 190
India 11 853 11 790 11 752 11 733 11 722
Indonesia 2 174 2 177 2 162 2 135 2 102
Maldives 3 3 3 3 3
Myanmar 389 392 399 407 416
Nepal 360 363 364 362 360
Sri Lanka 175 171 166 161 156
Thailand 465 473 478 481 484
Timor-Leste 16 16 16 16 16
Cancer Cervix burden in the Region
Asia has the highest burden of cervical cancer among all the continents, primarily due to the lack of organized cervical cancer screening in countries. Current estimates indicate that every year 284 823 Asian women are diagnosed with cancer cervix, the third most frequent cancer among women.
Countries in the WHO South-East Asia Region contribute nearly 175 000 new cancer cervix cases every year, which constitutes 35% of the global burden and 60% of the Asian burden of the disease.
Every year, an estimated 144 434 women die from cancer cervix in Asia, of which 102 665 women are from countries in the WHO South-East Asia Region. Cancer Cervix incidence and mortality rates in Member States of the Region are given in Table A9.3. It is to be noted that most of these countries do not have a systematic method of data collection through a population-based cancer registry.
The only source of such statistics is hospital-based cancer registries that collect data from patients attending hospitals for diagnosis and treatment. There is always a possibility of underreporting of the true incidence of cervical cancer if there is no robust method of data collection from the population.
Maldives and Timor-Leste do not have cancer diagnostic and treatment facilities, and as a result have no information on cervical cancer incidence and mortality.
About 10.9% of Asian women are estimated to harbour cervical HPV infection at any given time, and 68.5% of invasive cervical cancers are attributed to HPV types 16 or 18. The observed prevalence of HPV in normal women is quite variable among the individual countries in the Region. To some extent, such variability can be explained by differences in the selection of study subjects and the HPV detection technology used. However, the proportion of invasive cancers attributable to HPV types 16 and 18 (the vaccine-preventable types) is almost uniformly between 65% and 70% in these countries, indicating the high degree of protection expected from the currently available vaccines against HPV.
43 Table A9.3. Cancer Cervix incidence and mortality in Member States of the South-East Asia
Region (estimates for 2012)14
Country
Cancer Cervix incidence Cancer Cervix mortality
Source of incidence and mortality data
Bangladesh 11 956 19.2 6 582 11.5 No PBCR; hospital-based data
Bhutan 37 12.8 19 7.0 No PBCR; hospital-based data
DPR-Korea 1 881 12.4 1 119 7.2 No PBCR; hospital-based data
India 122 844 22.0 67 477 12.4 PBCR in select areas (<5%
population covered)
Indonesia 20 928 17.3 9 498 8.1 No PBCR; hospital-based data
Maldives 14 11.0 7 6.3 No PBCR; no data
Myanmar 5 286 20.6 2 998 12.3 No PBCR; hospital-based data
Nepal 2 332 19.0 1 367 12.0 No PBCR; hospital-based data
Sri Lanka 1 721 13.1 690 5.0 No PBCR; hospital-based data
Thailand 8 184 17.8 4 513 9.7 PBCR in select areas (~40%
population covered)
Timor-Leste - - - - No PBCR; no data
ASR – age standardized rates; PBCR – population-based cancer registry
Cancer Cervix control initiatives Bangladesh
The National Cervical Cancer Screening Programme was launched in Bangladesh in 2005. The guidelines formulated by a national advisory board recommended screening of women aged 30 years or above by visual inspection after acetic acid application (VIA) at an interval of three years. A national coordinating centre at Bangabandhu Sheikh Mujib Medical University, Dhaka is responsible for training of all service providers, setting up screening and colposcopy centres across the country, ensuring steady supply of consumables, and monitoring and evaluation of the programme. Initially, VIA services were set up in district hospitals and in maternity hospitals situated at district headquarters.
The screening services were subsequently expanded to subdistricts and rural health centres to improve access at the community level. Currently, screening is being offered at 57 district hospitals, 61 maternity clinics, 70 subdistrict hospitals and 50 rural health centres across the country. Nurses and gynaecologists attached to these centres are trained to perform VIA.
Referral centres for colposcopy and treatment have been set up at medical college hospitals in select districts maintaining a linkage with the screening centres. Colposcopy and treatment are performed by trained gynaecologists and non-specialist clinicians. If high-grade lesions are suspected on colposcopy, the women are offered immediate treatment (“see-and-treat”) without waiting for histologic confirmation. This has substantially reduced the non-compliance to treatment observed in the initial phase of the programme. At present, nearly 100 000 women are being screened every year and VIA-positivity is consistently around 5%. The programme is still predominantly opportunistic with a high level of central coordination. Despite a nationwide awareness campaign, the participation rate is still moderate.
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HPV vaccines are licensed in Bangladesh for opportunistic vaccination. There is no immediate plan to include the vaccine in the national immunization programme. There is no population-based cancer registry in the country.
Bhutan
A pilot project on cancer cervix screening was initiated in three districts in 2002. A national advisory committee recommended screening of 20 to 60 year old women using Pap smear cytology and referral of all positives to one designated colposcopy centre. The pilot project was completed in 2004 and reviewed in 2005. It was observed that Pap smears were of suboptimal quality (high rate of unsatisfactory smears) and, because the cytotechnicians were overburdened, there was a long reporting time for Pap smears. The loss to follow-up was high, with very few cytology-positive women attending the colposcopy centre. The programme was scaled up in 2005 by establishing new cytology laboratories and recruiting more trained cytotechnicians and pathologists. The number of centres with colposcopy and treatment facilities was also increased to four. Despite initial improvement in the performance of cytology, the programme remained ineffective due to lack of sustained motivation of staff, irregular supply of consumables and low participation rates. Recently, VIA by nurses has been introduced in select centres and a mobile outreach approach is being followed. The screening programme is still opportunistic with low uptake, and reaching women in geographically remote areas is a major challenge.
Under strong political patronage and support from external donors (Australian Cervical Cancer Foundation), a pilot project to vaccinate 12 to 18 year old girls was successfully conducted in 2009 and 2010. Since February 2011, the quadrivalent vaccine has been introduced into the national immunization programme. Every year, all girls reaching the age of 12 years are being vaccinated using a health facility-based approach. To date, no serious adverse event has been reported from the vaccinated girls.
There is no population-based cancer registry in the country.
Democratic People’s Republic of Korea
The facilities for managing invasive cervical cancer are poorly developed in the country. A national cervical cancer screening programme has recently been proposed as part of an overall improvement in health care for women. On the recommendation of a group of experts, a pilot project has been launched to screen women aged from 30 to 55 years by VIA in three regions. The rural clinics, rural hospitals and county/district hospitals have a list of beneficiaries (client list), from which it is possible to identify the women eligible for screening. Family health doctors, during their home visits, will counsel and motivate the eligible women to undergo screening. VIA will be done in rural and district/
county hospitals by nurses and gynaecologists. Colposcopy and biopsy will be arranged at provincial hospitals, where specialist gynaecologists will be trained to do the procedures. The colposcopy clinic at the maternity hospital in the capital city of Pyongyang will be upgraded as the main referral centre and also as the national coordinating centre. A group of gynaecologists have been trained in India who will serve as the master-trainers.
HPV vaccines are not available in the country, and there is no population-based cancer registry.
45 India
In spite of the high burden of the disease in the country, there is no organized cervical cancer screening programme in India. Pap smear cytology facilities are available at select laboratories in urban areas, although their quality varies widely. Women are advised Pap smear by gynaecologists only if they have symptoms suggestive of cervical cancer or the cervix looks unhealthy on naked eye examination. The concept of routine screening of asymptomatic women is almost non-existent. A group of experts drafted national guidelines for cervical cancer screening in 2005. The recommendations were to screen women aged from 30 to 59 years using VIA and to set up a two-tier system to perform screening at primary health centres and colposcopy at district hospitals.
Dissemination of the guidelines was poor and no action was taken on its basis. As a result, the public health system (at least at the primary and secondary levels) does not have any capacity or infrastructure to perform cervical cancer screening or manage screen-positive women with colposcopy and treatment. The level of awareness regarding cervical cancer and its prevention among health policy-makers, health professionals and the general public is very low. A new programme for control of all major noncommunicable diseases including cancer was introduced in 2012, with dedicated funds for cancer control, through a community-oriented approach. The operational guidelines of the new programme recommend cervical cancer screening for women, although the details of implementation issues are lacking.
India is a vast country with much heterogeneity among the provinces in terms of political commitment to health care, socioeconomic situation and capacity of health systems. The need of the hour is to draft a pragmatic operational guideline for cervical cancer screening, based on which steps should be taken to integrate screening in health facilities, augment the capacity of the health system to make screening and colposcopy services accessible to women, and train a critical number of health-care providers to deliver the services.
Both bivalent and quadrivalent vaccines are licensed in India. The vaccines are being administered only to those girls and women paying from their own pocket. A demonstration project initiated by Program for Appropriate Technology in Health (PATH) in two provinces was stopped prematurely due to the reported deaths of vaccinated girls. Subsequent investigations into the causes of death did not find any causal association with the vaccine. The adverse media publicity associated with the reported deaths resulted in a very lukewarm acceptance of the vaccines, even in the private sector.
There are well organized population-based cancer registries in several provinces under the National Cancer Registry Programme. Despite this, the population covered by all these registries together is less than 5% of the total national population.
Indonesia
A national cancer cervix screening programme was launched in the country in 2007, with the objective of screening 30 to 50 year old women every 5 years. The Cervical and Breast Cancer Prevention (CECAP) project developed a service delivery model that was piloted in the district of Karawang, east of Jakarta, from January 2007 to December 2011. The single-visit approach of screening by VIA followed by cryotherapy of VIA-positive women was evaluated. Although this single-visit approach was acceptable and could improve compliance to treatment, ensuring the steady supply of refrigerant gas for cryotherapy was a problem. The CECAP project was subsequently up-scaled and currently the services are being provided in 347 primary health centres situated in 23 provinces. However, services are grossly inadequate for the large target population and a lot of investment is required to improve the infrastructure and build capacity to ensure access of the entire female population to cervical cancer screening services.
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Both HPV vaccines are available in the private market and are considered too costly to be considered for the national immunization programme. School-based vaccine delivery services have been very successful in achieving high coverage of other childhood vaccines. The existing health-promoting schools and adolescent-friendly health services programme targeted towards boys and girls aged from 6 to 19 years provide a great opportunity for introduction of HPV vaccines.
There is no population-based cancer registry; hospital-based cancer registries exist in 23 teaching hospitals.
Maldives
There is no radiation therapy facility in the country. Only those cervical cancer patients who can afford to go abroad have the opportunity for treatment. It is essential for the country to have a cervical cancer control programme, which is non-existent to date. Currently only one tertiary care hospital in the capital city of Malé has a laboratory equipped to process and read Pap smear cytology.
Pap smears are advised only to women suspected of having cervical cancer and are rarely followed up with colposcopy.
A pilot cervical cancer screening project is being planned, to be implemented in Malé and another province. Women between 30 and 50 years of age will be screened by VIA performed by trained nurses. VIA-positive women will be referred to tertiary care hospitals in Malé where colposcopy units will be set up. Getting trained clinicians who can spare time for the programme is a major challenge for the country.
There is no plan to introduce HPV vaccines in the national immunization programme in the near future. There are no population-based or hospital-based cancer registries.
Myanmar
Myanmar has a high burden of cervical cancer due to the lack of any organized screening programme.
Although a national cancer control programme was launched in 2008, the cervical cancer screening component was never organized appropriately to ensure access to the population.
HPV vaccines are available in the private sector. A policy for the introduction of new vaccines into the national immunization programme (drafted in 2012 and accepted by the Ministry of Health) advocated HPV vaccine, although as a second priority. The national immunization programme for other common vaccines has high coverage in the country. There are well developed school-based health intervention programmes as well as out-of-school adolescent health programmes that can be used for the delivery of HPV vaccines. However, financing and ensuring the logistics for a three-dose vaccine are challenges for the future HPV vaccination programme to overcome.
There are no population-based cancer registries. Hospital-based cancer registries function from three hospitals providing radiation therapy facilities.
Nepal
The national guideline on cervical cancer screening and prevention (drafted in 2010) recommended the use of VIA as the screening test and a single-visit approach (VIA followed by cryotherapy of VIA-positive women in the same sitting) to improve compliance to treatment. There was no concerted effort to roll out screening services, possibly because of other competing health priorities. In 2012,
47 the Family Health Division reorganized the cervical cancer screening programme to screen women
aged from 30 to 60 years at least once in the next 5 years. The screening services are presently more community-oriented and additional midwives and nurses have been trained to perform VIA.
A group of medical officers and gynaecologists has been trained in colposcopy and management of cervical precancers. Linkage between the screening centres and hospitals offering colposcopy services has been created and efforts are being made to connect the cervical cancer screening database to the medical information system.
The Nepal Network for Cancer Treatment and Research initiated vaccination of small cohorts of 12 to 14 year old girls each year, starting from 2008, with funding support from Australian Cervical Cancer Foundation. The country is yet to obtain sustainable funding to introduce the vaccine into the national immunization programme. Existence of other school-based health programmes for adolescent girls such as the measles-rubella vaccination campaign, de-worming or school nutrition programme offer a good opportunity to access the girls for HPV vaccination. The lack of a regular power supply makes maintenance of the cold chain a challenging task.
There is no population-based cancer registry in the country.
Sri Lanka
The Government of Sri Lanka initiated the ‘Well Woman’s Clinic” (WWC) programme with the support of UNFPA in 1996, focusing on reproductive health needs of women above 35 years of age. The programme is built on the existing primary health care infrastructure and integrated into existing MCH/FP package. PAP smear was introduced for cervical cancer screening in 1998.
Guidelines and protocols for cervical cytology screening was first developed in the year 2006 and were subsequently revised in 2010. Since the cervical cancer screening coverage remained very low over the years a decision was taken in year 2007 to actively target the women of 35 years of age for organized screening. However, this decision to actively campaign for 35 year old women does not preclude any woman (especially women over 35 years) attending the WWC since these clinics offer screening services for other conditions such as hypertension and diabetes as well. Over the last three years a steady increase of the percentage coverage of the organized screening of the focus target group of 35 yr old women is noted. The Public Health Midwives identify the 35 year old women From the registers maintained at the Public Health Midwives Office (PHM’s office) and counsel them to undergo cervical cancer screening. Pap smears are collected by Medical officers or Public Health Nursing Sisters at the clinics. In 2012 women have had about 140,000 pap smears.
There are more than 900 Well Woman Clinics spread all over the country at present. These WWC clinics are linked to designated histopathology laboratories. At present there are 35 laboratories capable of processing and interpreting Pap smear cytology across the country. There is a 6-8 weeks of lag period between smear taking and delivery of reports. Sometimes the gap may be even longer since the technicians and the pathologists in certain centers are overloaded with their other routine work. The cytology reports are sent to the relevant Medical Officer of Health Office by the particular lab for distribution among the clients by the Public Health Midwife.
There are 20 colposcopy centres in country mostly situated in provincial hospitals or tertiary care
There are 20 colposcopy centres in country mostly situated in provincial hospitals or tertiary care